Clinical Review

Minimal to mild endometriosis: 4 treatment options

OBG Manag. 2004 May;16(5):46-58

References

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When no operative laparoscopy is performed or when resection of endometriosis is incomplete, pain patients are usually best managed with GnRH agonists or danazol for 3 to 6 months (TABLE). (GnRH agonists are generally preferred because of their more favorable side-effect profile.) If pain continues despite surgical and/or medical treatment, refer the patient to pain specialists for a comprehensive management approach. Discuss this option with the patient at her first consultation and integrate it into the treatment plan.

For infertility patients who have not undergone operative resection or who have had inadequate resection, minimal and mild disease needs no further treatment. Ovarian suppression should be avoided. Patients who do not conceive within approximately 6 to 15 months should generally move on to in vitro fertilization, although repeat laparoscopy is occasionally indicated if there is residual disease and pain associated with the infertility.

TABLE

Reports of pain in patients with laparoscopically diagnosed endometriosis treated with nafarelin acetate or danazol

TREATMENT	DYSMENORRHEA			DYSPAREUNIA				PELVIC
	NO.	%		NO.	%			NO.	%
	NO.	ABSENT	PRESENT	NO.	ABSENT	PRESENT	NOT REPORTED	NO.	ABSENT	PRESENT
Nafarelin 800 μg daily	45			26					40
Admission		0	100		0	100	0		0	100
Treatment*		100	0		62	31	8		65	35
Posttreatment^†		36	64		62	35	4		45	55
Nafarelin 400 μg daily	45			31				37
Admission		0	100		0	100	0		0	100
Treatment*		98	2		65	32	3		57	43
Posttreatment^†		33	67		71	29	0		49	51
Danazol 400 mg bid	34			23				28
Admission		0	100		0	100	0		0	100
Treatment*		94	6		70	17	13		64	36
Posttreatment^†		50	50		65	30	4		50	50
bid = twice a day
All subjects reported pain on admission.
*Treatment was continued for 6 months
†Posttreatment period was 6 months follow-up
Source: Adamson and Kwei²⁰

Treat the whole patient: Lifestyle and other factors

It is critical that physicians recognize the degree to which endometriosis can physically and emotionally disrupt patients’ lives. Understanding, empathy, and a comprehensive management approach are valuable components of successful treatment.

The patient also should be encouraged to develop a healthy lifestyle with respect to diet, exercise, and sleep. Stress reduction through mind-body techniques can be very helpful, as well.

If pain continues despite surgical or medical treatment, refer the patient to pain specialists for comprehensive management.

Information about the disease can serve as psychological support and is available from organizations such as the Endometriosis Association (www.endometriosisassn.org), RESOLVE (www.resolve.org), and the American Society for Reproductive Medicine (www.asrm.org). Personal or group counseling also may be helpful, especially for the patient with chronic pain.

Some patients may seek nontraditional and unproven approaches to treatment, such as acupuncture, herbal medicine, or special diets. Management in these chronic, complex situations should focus on alleviation of symptoms and improved quality of life.

A comprehensive evaluation of gastrointestinal, genitourinary, musculoskeletal, neurologic, and psychological systems may be indicated. Referral to a pain clinic may be helpful for further treatment, including biofeed back strategies, nerve blocks, psychotherapy, or other pain-management techniques.

Treatment of reactive depression frequently is necessary and often requires a multidisciplinary approach.

A comprehensive long-range treatment approach should be individualized to the patient. A complete cure can sometimes be achieved only by total hysterectomy and bilateral salpingo-oophorectomy.

Dr. Adamson reports no financial relationships relevant to this article.